GNRS 555: Exam 1 - Your Roadmap to
Success
Where are the pulse sites? - Temporal, carotid, brachial, radial, ulnar, apical,
femoral, popliteal, tibial, dorsal pedis
Discuss physiological changes associated with fever. - Vasodilation, sweating,
inhibition of heat production. Hypothalamus raises set point of internal temp and
body produces/conserves heat. Chills, shivers, and feeling cold as body goes to new
set point. Increased heart and respiratory rates
What is radiation in heat loss? - The transfer of heat from the surface of one object to
the surface of another without direct contact between the two.
(vasodilation/vasoconstriction)
What is conduction in heat loss? - The transfer of heat from one object to another
with direct contact. (touching a cold table with warm hand)
What is convection in heat loss? - The transfer of heat away by air movement. A fan
promotes heat loss through convection. (moistened skin in moving air)
What is evaporation in heat loss? - The transfer of heat energy when a liquid is
changed to a gas. The body continuously loses heat by evaporation.
(perspiration/sweating)
What is diaphoresis in heat loss? - Visible perspiration primarily occurring on the
forehead and upper thorax, although it occurs in other places on the body.
What are the patterns of fever? - -Sustained: A constant body temperature
continuously above 38°C (100.4°F) that has little fluctuation
-Intermittent: Fever spikes interspersed with usual temperature levels (Temperature
returns to acceptable value at least once in 24 hours.)
-Remittent: Fever spikes and falls without a return to acceptable temperature levels.
-Relapsing: Periods of febrile episodes and periods with acceptable temperature
values (Febrile episodes and periods of normothermia are often longer than 24
hours.)
Describe nursing measures that promote heat loss and heat conservation. - •
Education
• Obtain cultures of body fluids such as urine, sputum, or blood (before beginning
antibiotics) if ordered. Obtain blood specimens to coincide with temperature spikes,
when the antigen-producing organism is most prevalent.
• Minimize heat production: reduce frequency of activities that increase oxygen
demand such as excessive turning and ambulation; allow rest periods; limit physical
activity.
• Maximize heat loss: reduce external covering on patient's body without causing
shivering; keep patient, clothing, and bed linen dry.
• Satisfy requirements for increased metabolic rate: provide supplemental oxygen
therapy as ordered to improve oxygen delivery to body cells; provide measures to
,stimulate appetite and offer well-balanced meals; provide fluids (at least 8 to 10 [8-
oz] glasses for patients with normal cardiac and renal function) to replace fluids lost
through insensible water loss and sweating.
• Promote patient comfort: encourage oral hygiene because oral mucous
membranes dry easily from dehydration; control temperature of the environment
without inducing shivering; apply damp cloth to patient's forehead.
• Identify onset and duration of febrile episode phases: examine previous
temperature measurements for trends,
• Control environmental temperature to 21° to 27°C (70° to 80°F)
You notice that a teenager has an irregular pulse. The best first action you should
take includes which one of the following?
A. Reading the history and physical.
B. Assessing the apical pulse rate for 1 full minute.
C. Auscultating for strength and depth of pulse.
D. Asking whether the patient feels any palpitations or faintness of breath. - B.
Assessing the apical pulse rate for 1 full minute.
What are the steps of respiration? - Ventilation, Diffusion, Perfusion
What factors influence respirations? - Exercise, acute pain, anxiety, smoking, body
position, medications, neurological injury, hemoglobin function
What impedes SpO2 measurement? - Dark and/or sparkly nail polish, jaundice,
carbon monoxide, patient motion, outside light, darker skin, cold hands
Upon assessment, you find your postoperative patient to be breathing rapidly. You
should immediately do which one of the following?
A. Call the physician.
B. Count the respirations.
C. Assess the oxygen saturation.
D. Ask the patient if he feels uncomfortable. - C. Assess the oxygen saturation.
What is pulse pressure and what is the normal range? - Difference between systolic
and diastolic pressures. Normal range = 30-50
What factors influence blood pressure? - Age, stress, ethnicity, sex, daily variation,
medications, activity, weight, smoking
What can happen if the BP cuff is too small? - It can have a reading that is too high.
(little cuff that is working too hard to compress, has an elevated reading)
What can happen if the BP cuff is too big? - It can have a reading that is too low.
What is the ideal size of a BP cuff? - 40% circumference, 2/3 (80%) of arm length
What systolic range qualifies for hypotension? - <90mmHg
What is more common, hypertension or hypotension? - Hypertension
, What is orthostatic blood pressure? - Taking the blood pressure when they are lying
down, sitting, and standing
How do you calculate mean arterial pressure (MAP)? - average pressure in arteries
during one cardiac cycle. (systolic + 2(diastolic))/ 3 (example: (120+2(80))/3) = 93.3
What are metabolic effects of immobilization? - Alterations in endocrine, calcium
absorption, and GI function
What are respiratory effects of immobilization? - Atelectasis (collapse of alveoli) and
hypostatic pneumonia (inflammation of lung from stasis)
What are cardiovascular effects of immobilization? - Orthostatic hypotension,
thrombus
What are musculoskeletal effects of immobilizaiton? - Loss of endurance and muscle
mass and decreased stability and balance
What are muscle effects of immobilization? - Loss of muscle mass, muscle atrophy
What are skeletal effects of immobilization? - Impaired calcium absorption and joint
abnormalities (joint contracture)
What are urinary effects of immobilization? - Urinary stasis, UTI, renal calculi
What are integumentary effects of immobilization? - Pressure ulcer, ischemia
You notice a respiratory change in your immobilized postoperative patient. The
change you note is most consistent with:
A. Atelectasis
B. Hypertension.
C. Orthostatic hypotension.
D. Coagulation of blood. - A. Atelectasis
Who is at the greatest risk for pressure ulcers? - Older adults with bony
prominences, overweight adults, those with neurological issues
How often do you turn a patient to prevent pressure ulcers? Who is responsible if
this is forgotten? - Every two hours. The primary nurse is responsible if it does not
get done even if it is delegated
What are psychosocial effects of immobility? - -Emotional and behavioral: hostility,
fear, anxiety
-Sensory alterations: altered sleep patterns
-Changes in coping: depression, sadness
What age group is most at risk for developmental changes due to immobility? -
Infants, toddlers, and preschoolers (the older the patient, the less problematic on
development)
Success
Where are the pulse sites? - Temporal, carotid, brachial, radial, ulnar, apical,
femoral, popliteal, tibial, dorsal pedis
Discuss physiological changes associated with fever. - Vasodilation, sweating,
inhibition of heat production. Hypothalamus raises set point of internal temp and
body produces/conserves heat. Chills, shivers, and feeling cold as body goes to new
set point. Increased heart and respiratory rates
What is radiation in heat loss? - The transfer of heat from the surface of one object to
the surface of another without direct contact between the two.
(vasodilation/vasoconstriction)
What is conduction in heat loss? - The transfer of heat from one object to another
with direct contact. (touching a cold table with warm hand)
What is convection in heat loss? - The transfer of heat away by air movement. A fan
promotes heat loss through convection. (moistened skin in moving air)
What is evaporation in heat loss? - The transfer of heat energy when a liquid is
changed to a gas. The body continuously loses heat by evaporation.
(perspiration/sweating)
What is diaphoresis in heat loss? - Visible perspiration primarily occurring on the
forehead and upper thorax, although it occurs in other places on the body.
What are the patterns of fever? - -Sustained: A constant body temperature
continuously above 38°C (100.4°F) that has little fluctuation
-Intermittent: Fever spikes interspersed with usual temperature levels (Temperature
returns to acceptable value at least once in 24 hours.)
-Remittent: Fever spikes and falls without a return to acceptable temperature levels.
-Relapsing: Periods of febrile episodes and periods with acceptable temperature
values (Febrile episodes and periods of normothermia are often longer than 24
hours.)
Describe nursing measures that promote heat loss and heat conservation. - •
Education
• Obtain cultures of body fluids such as urine, sputum, or blood (before beginning
antibiotics) if ordered. Obtain blood specimens to coincide with temperature spikes,
when the antigen-producing organism is most prevalent.
• Minimize heat production: reduce frequency of activities that increase oxygen
demand such as excessive turning and ambulation; allow rest periods; limit physical
activity.
• Maximize heat loss: reduce external covering on patient's body without causing
shivering; keep patient, clothing, and bed linen dry.
• Satisfy requirements for increased metabolic rate: provide supplemental oxygen
therapy as ordered to improve oxygen delivery to body cells; provide measures to
,stimulate appetite and offer well-balanced meals; provide fluids (at least 8 to 10 [8-
oz] glasses for patients with normal cardiac and renal function) to replace fluids lost
through insensible water loss and sweating.
• Promote patient comfort: encourage oral hygiene because oral mucous
membranes dry easily from dehydration; control temperature of the environment
without inducing shivering; apply damp cloth to patient's forehead.
• Identify onset and duration of febrile episode phases: examine previous
temperature measurements for trends,
• Control environmental temperature to 21° to 27°C (70° to 80°F)
You notice that a teenager has an irregular pulse. The best first action you should
take includes which one of the following?
A. Reading the history and physical.
B. Assessing the apical pulse rate for 1 full minute.
C. Auscultating for strength and depth of pulse.
D. Asking whether the patient feels any palpitations or faintness of breath. - B.
Assessing the apical pulse rate for 1 full minute.
What are the steps of respiration? - Ventilation, Diffusion, Perfusion
What factors influence respirations? - Exercise, acute pain, anxiety, smoking, body
position, medications, neurological injury, hemoglobin function
What impedes SpO2 measurement? - Dark and/or sparkly nail polish, jaundice,
carbon monoxide, patient motion, outside light, darker skin, cold hands
Upon assessment, you find your postoperative patient to be breathing rapidly. You
should immediately do which one of the following?
A. Call the physician.
B. Count the respirations.
C. Assess the oxygen saturation.
D. Ask the patient if he feels uncomfortable. - C. Assess the oxygen saturation.
What is pulse pressure and what is the normal range? - Difference between systolic
and diastolic pressures. Normal range = 30-50
What factors influence blood pressure? - Age, stress, ethnicity, sex, daily variation,
medications, activity, weight, smoking
What can happen if the BP cuff is too small? - It can have a reading that is too high.
(little cuff that is working too hard to compress, has an elevated reading)
What can happen if the BP cuff is too big? - It can have a reading that is too low.
What is the ideal size of a BP cuff? - 40% circumference, 2/3 (80%) of arm length
What systolic range qualifies for hypotension? - <90mmHg
What is more common, hypertension or hypotension? - Hypertension
, What is orthostatic blood pressure? - Taking the blood pressure when they are lying
down, sitting, and standing
How do you calculate mean arterial pressure (MAP)? - average pressure in arteries
during one cardiac cycle. (systolic + 2(diastolic))/ 3 (example: (120+2(80))/3) = 93.3
What are metabolic effects of immobilization? - Alterations in endocrine, calcium
absorption, and GI function
What are respiratory effects of immobilization? - Atelectasis (collapse of alveoli) and
hypostatic pneumonia (inflammation of lung from stasis)
What are cardiovascular effects of immobilization? - Orthostatic hypotension,
thrombus
What are musculoskeletal effects of immobilizaiton? - Loss of endurance and muscle
mass and decreased stability and balance
What are muscle effects of immobilization? - Loss of muscle mass, muscle atrophy
What are skeletal effects of immobilization? - Impaired calcium absorption and joint
abnormalities (joint contracture)
What are urinary effects of immobilization? - Urinary stasis, UTI, renal calculi
What are integumentary effects of immobilization? - Pressure ulcer, ischemia
You notice a respiratory change in your immobilized postoperative patient. The
change you note is most consistent with:
A. Atelectasis
B. Hypertension.
C. Orthostatic hypotension.
D. Coagulation of blood. - A. Atelectasis
Who is at the greatest risk for pressure ulcers? - Older adults with bony
prominences, overweight adults, those with neurological issues
How often do you turn a patient to prevent pressure ulcers? Who is responsible if
this is forgotten? - Every two hours. The primary nurse is responsible if it does not
get done even if it is delegated
What are psychosocial effects of immobility? - -Emotional and behavioral: hostility,
fear, anxiety
-Sensory alterations: altered sleep patterns
-Changes in coping: depression, sadness
What age group is most at risk for developmental changes due to immobility? -
Infants, toddlers, and preschoolers (the older the patient, the less problematic on
development)
